Forceps Left in Rhode Island Hospital Patient Nets $300,000 Fine

Forceps left in Rhode Island Hospital patient has netted a $300,000 fine from the Rhode Island Department of Health (HEALTH).

HEALTH reports the fine has been levied due to RIH’s repeated failure to follow established policy and failure to adequately address staff reports of problems that could result in medical errors.

RIH most recent error involves finding a surgical instrument in a patient 3 months after surgery. HEALTH confirmed to Eyewitness News that the patient had surgery on July 13th and was found to have forceps in the abdominal area when a diagnostic imaging procedure was done on October 15th for an unrelated issue.

Prior to this, HEALTH had received notification in August from Rhode Island Hospital that during a neurosurgery procedure at RIH on August 4, 2010, a piece of a broken drill bit was left in the patient’s skull after the surgery was completed.

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HEALTH’s joint investigation with the Center for Medicare & Medicaid Services (CMS) has discovered that the hospital is not actively ensuring that the operating room staff is following existing hospital policy. RIH’s surgical count policy states that if a surgical tool or device is unaccounted for at the end of surgery, an x-ray of the patient should be done before the patient leaves the operating room to assure that the tool or device is not inside the patient. In the drill bit incident, no x-ray was taken and the surgical count was documented as correct.

HEALTH also found that numerous staff reports of incorrect surgical counts have gone unanswered by the hospital. Similarly, reports from nursing staff that an anesthesiologist did not wear a surgical mask in the operating room were not addressed by medical leadership.

“There is a troubling pattern of disregard for established policies that are designed to protect patient safety and prevent medical errors in Rhode Island Hospital’s operating rooms,” said Director of Health David R. Gifford, MD, MPH. “When reports from staff about problems in the operating rooms are not adequately addressed, employees are less likely to speak up and report potential problems or concerns.”

RIH must submit a plan of correction to HEALTH by November 10, 2010, and must pay the fine by November 24, 2010.

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